Woman’s Health History

First Name:

Last Name:

Email:

How often do you check your e-mail:

Home Phone:

Work Phone:

Mobile Phone:

Age:

Height:

Birthdate:

Current Weight:

Weight six months ago:

One year ago:

Would you like your weight to be different?:

If so, what?:

Social Information


Relationship status:

Where do you currently live?:

Children:

Pet:

Occupation:

Health Information


Please list your main health concerns:

Other concerns and/or goals?:

At what point of your life did you feel best?:

Any serious illnesses/hospitalizations
/injuries?:

How is/was the health of your mother?:

How is/was the health of your father?:

What is your ancestry?:

What blood type are you?:

How is your sleep?:

How many hours?:

Do you wake up at night?:

Why?:

Any pain, stiffness or swelling?:

Constipation/Diarrhea/Gas?:

Allergies or sensitivities? Please explain:

Are your periods regular?:

How many days is your flow?:

How frequent?:

Painful or symptomatic? Please explain:

Reached or approaching menopause?
Please explain:

Birth control history:

Do you experience yeast infections or
urinary tract infections? Please explain:

Medical Information


Do you take any supplements or medications? Please list:

Any healers, helpers or therapies with which you are involved? Please list::

What role do sports and exercise play in your life?:

Food Information


What foods did you eat often as a child?

Breakfast:

Lunch:

Dinner:

Snacks:

Liquids:

Will family and/or friends be supportive
of your desire to make food and/or
lifestyle changes?:

Do you cook?:

What percentage of your food is
home-cooked?:

Where do you get the rest from?:

Do you crave sugar, coffee, cigarettes,
or have any major addictions?:

The most important thing I should
do to improve my health is?:

Additional Comments


Anything else you would like to share?: